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What can your team do to improve workflow and enhance the experience of our members and patients? What else could your team do to make KP the best place to work and receive care?
What
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As a union partnership representative (UPR) from UFCW Local 770, Annamarie Marin helps support 72 unit-based teams at the West Los Angeles Medical Center. Last year, she helped the Oncology team overcome low morale to move from Level 2 to Level 4—and it’s now on the cusp of achieving Level 5. Marin recently was interviewed about her role as a UPR by LMP Communications Manager Sherry Crosby.
A. I have been part of UBTs since 2005. I started as a co-lead and then became an executive sponsor. This experience helped me tremendously, because I can relate to the teams on a personal level. I have been in the exact same place, dealing with similar challenges.
A. Some teams need team-building exercises, while others need to learn to trust one another and share information on projects. Starter teams don’t know how to create agendas or structure meetings, so I help facilitate their meetings. The most important thing is making sure I’m available and that teams have what they need to succeed.
A. They were struggling with membership involvement and morale was low. Nobody wanted to participate in meetings.
A. I helped staff members understand that the UBT is not there to add work to their plate. Eventually, we got a group to participate in team meetings.
We went through different trainings and started on small projects. First, they focused on staff morale. Staff members practiced expressing appreciation for each other until it became part of the team's culture. Then they moved to an affordability project. That was a pivotal point in that team’s development, because the idea came from a labor partner.
It shows team members are involved in decision making and contributing to the department’s success.
A. I helped the team members understand their work through a different lens—what the function of a UBT is, and their role in it. They realized they have a great department and an engaged manager. It was really about helping them understand their value to each other.
Early in her nursing career, Yvonne Roddy-Sturm, now the chief nursing executive at Ontario Medical Center in Southern California, saw that caregiver diversity—or lack of it—matters.
“I saw differences in how some providers cared for people,” she says. “It wasn’t just based on race—economic status, language, lots of things came into play. We all make assumptions about others.”
The consequences of such assumptions are serious, impacting the quality of care a patient receives and leading to a wide range of health disparities.
In the 30 years Roddy-Sturm has been with Kaiser Permanente, our member and patient population has become more diverse—as has our workforce. And that’s helped KP deliver high-quality, patient-centered care.
“Patients who can relate to their caregiver are more likely to follow their treatment regimen,” says Roddy-Sturm. “They’re more likely to ask questions of people who are more like them.”
The Labor Management Partnership plays a significant role in building the skills, cultural competence and work environment needed to serve KP’s diverse patient population.
For example:
And there’s more. Many departments, including Ontario’s nursing department, make their diverse teams part of the hiring process.
“We always start with the skills required to do the job,” says Roddy-Sturm. “Then our panel members bring their own insights and diversity to the discussion. They look for fit, flexibility, compassion and empathy, as well as skill. We try to live our values.”
Research shows that patients fare better when they receive care in their preferred language and providers demonstrate sensitivity and respect for their cultural beliefs and values.
Frontline teams across Kaiser Permanente are doing just that, and nowhere is this more apparent than in California, where 85 percent of KP’s Latino members live. The Northern and Southern California regions have developed language assistance programs that help eliminate health disparities and personalize the care experience for patients, including:
“When we show respect for our patients’ cultures and values, we are more likely to provide better care, because they trust us and are more likely to follow through on the instructions we give them,” says Andrea Rudominer, MD, senior physician for Pediatrics and chief of diversity for the San Jose Medical Center. “Culturally competent care leads to better health outcomes for all of our patients.”
Brandon Johnson was close to giving up on his dream of becoming an X-ray technician.
Born with sickle cell disease, a genetic blood disorder that primarily affects African-Americans, the 35-year-old Southern California man was forced to drop out of school for semesters at a time.
But thanks to the sickle cell care team at the Inglewood Medical Offices, Johnson is now on medication that reduces complications. Last fall, he was able to complete his studies, and he has started looking for a radiology job.
“They got me on a plan to keep me out of the hospital,” says Johnson, who drives 60 miles one way from his Riverside home to see his doctor in Inglewood, even though other providers are closer. “If I didn’t have my health, I wouldn’t be where I am today.”
Johnson’s success is not uncommon for the Level 5 unit-based team, a group of physicians, managers and employees that provides personalized care for nearly 500 sickle cell patients in Southern California. About 300 of the region’s adult patients are treated directly by the team. Its approach is working—only five of the 300 needed frequent hospitalization and emergency care in the past year.
“Our goal is to keep sickle cell patients out of the hospital by giving them the care they need,” says Pippa Stewart, Inglewood’s department administrator.
Nationwide, about 70,000 people have sickle cell disease, which can cause chronic anemia, acute pain, infections and stroke. Although most are African-American, the disease also affects people of Indian, Middle Eastern, Hispanic and Mediterranean heritage. Patients often get stigmatized as drug addicts when they ask for narcotics to deal with their pain.
The current UBT grew out of a team that was established in 1999; before that, there was no comprehensive treatment program for KP’s sickle cell patients.
“Ninety percent of patients were getting their primary care in the emergency room,” says Shirley Brown, RN, a UNAC/UHCP member and the team’s care manager. Patients saw as many as 17 doctors as they went from appointment to appointment.
Now, the 12-member UBT—which includes four physicians, two registered nurses, a physician assistant, a pharmacist and a social worker—helps patients control symptoms by offering pain management care, providing resources such as a case manager, and urging them to keep appointments, which help minimize visits to the emergency room and hospital.
Team members coordinate with and help train the KP providers who care for the region’s remaining 200 patients. Last fall, Brown helped lead a session for 70 registered nurses from around the region. Osbourne Blake, MD, an internist and the team’s lead physician, provides regular updates to fellow physicians. “We’re trying to get everyone on the same page,” says Dr. Blake. A recent test of change focused on reducing the number of patients who miss appointments. For three months, Brown and a co-worker called patients every day to remind them about upcoming visits. The calls helped. The team’s “no-show appointment” rate dropped from 20 percent in May 2015 to 14 percent in August 2015.
“They all know you personally,” says Ryan Hull, a 27-year-old TV production assistant and film student. A few short years ago, he suffered frequent crises that required immediate medical attention. After he and his physician co-created a pain management program, his health improved dramatically.
“They did everything they could to find out what regimen works for me,” Hull says of staff members, who greet him by first name and offer walk-in appointments to accommodate his sometimes unpredictable schedule. “They figured out the perfect way to treat me.”
The Colorado region is improving patient care and saving millions by providing high-risk patients extra attention after discharge, leading to a reduction in readmission rates. In the Post Acute Care Transitions (PACT) program, nurse practitioners visit patients in their homes after discharge from a hospital or skilled nursing facility, giving them a chance to alter the patient’s care plan if needed. The PACT team has visited approximately 4,200 high-risk patients since the program began in January 2013. At that time, 22 percent of high-risk patients were readmitted within 30 days, at a cost of $11.7 million. The PACT team has reduced readmission rates by 50 percent, saving Kaiser Permanente approximately $6 million since the program began.
To make sure no good deed goes uncopied, the Georgia region launched a Spread and Sustain system to move best practices throughout the region—and showed off the results to KP’s board of directors at a UBT fair early last summer. Georgia took a spread blueprint from the Southern California region and fine-tuned it to meet its needs. Now its unit-based teams, sponsors and regional leaders identify projects with good spread potential, determine other locations where the new process could work, share the practice and check back to see how they’re being sustained. Several projects have been successfully spread region-wide—addressing such issues as hypertension, HPV vaccinations and lab specimen collection.
Hawaii is a beautiful place to live, but Kaiser Permanente members who live on the less-populated islands sometimes find it challenging to get the care they need. To address that, KP offers a special benefit called Travel Concierge Service. If health plan members need medical care that isn’t available on their island, KP assists them in traveling to the Moanalua Medical Center in Oahu or to a specialty care medical office. KP makes the travel arrangements and picks up the tab for travel, including airfare, shuttle service and discounted hotel rates. For minors who need specialty care, KP also pays for companion travel. “Our members love this service,” says Lori Nanone, a sales and account manager in the region.
For several years, co-leads in the Mid-Atlantic States have compiled monthly reports of their UBT activities, goals and progress using Microsoft Word and Excel. Now, the region is rolling out a dashboard that automatically compiles the same information from UBT Tracker into an easy-to-reference SharePoint site, Kaiser Permanente’s new online social collaboration tool. The new dashboard will encourage more frequent updates to UBT Tracker and eliminate the need for co-leads to create separate documents, says Jennifer Walker, lead UBT consultant and improvement advisor. “Now the information we get is more timely and easier to assess,” Walker says. “Before, the information was up to a month old.”
The Santa Rosa Medical Center Diversity Design committee is equipping employees with tools to help them provide better service to Spanish-speaking patients. The group, composed of labor and management, has been piloting a handout featuring a list of common Spanish phrases, such as ¿Necesita un intérprete? (“Do you need an interpreter?”), as well as instructions on using the phone interpreter system. The idea came from a Spanish-speaking patient on the facility’s Latino patient advisory committee, who recalled the time she was lost in the facility and no one could direct her in Spanish. The Spanish language flier is the latest in the committee’s work to help ensure all patients receive the same optimal service and care.
Unit-based teams in the Continuing Care Services department are focusing on improving the experience for some of Kaiser Permanente’s most vulnerable members: those in skilled nursing facilities or receiving home health, hospice or palliative care. Teams are focusing on ensuring better transitions for patients as they go from inpatient to ambulatory care. By identifying issues before they become problems, labor and management hope to coordinate care more effectively, reduce emergency department visits and cut down on outside medical costs.
Harmony comes easily when you use the tools of partnership. Just ask the Biohazards, a band of union members and a manager that uses partnership principles to guide performances. “We call ourselves an LMP project,” says Mary Anne Umekubo, a clinical laboratory scientist and Regional Laboratory assistant director who sings and plays percussion and guitar. She is among six band members who represent a variety of departments, shifts and unions, including SEIU-UHW and UFCW Local 770. Performing for friends and colleagues, band members use consensus decision making to choose songs, interest-based problem solving to fix mistakes and the Rapid Improvement Model to tweak performances. “We’re from different departments,” says drummer Eric Cuarez, a regional courier driver and SEIU-UHW member. “We come together to play music.”
Like casts and splints, X-rays are a routine part of patient care in the Orthopedics department at South Bay Medical Center. Unfortunately, missed copays for those X-rays were becoming common as well.
“Patients will get their X-rays done at the end of the visit—and then walk out without realizing that they owe a copay,” says Christopher Kresch, department administrator for Orthopedics and the team’s management co-sponsor. At other times, patients will unexpectedly need X-rays during their visit, and because the orders are placed during the exam, the charges are not captured during check-in.
So the team borrowed a practice from the Los Angeles Medical Center and developed a check-in sheet that shows, at a glance, if a patient has an outstanding X-ray copay. The team also adjusted its workflow to ensure that a staff member walks the patient to the front desk to pay the fee by the end of the visit.
Here’s how the process works:
The receptionist gives the check-in sheet to each patient at the start of the visit. As patients travel through the clinic to receive care, the form goes with them, enabling staff to conduct “warm hand-offs” by writing notes to each other about the patient’s care. When a copay is owed, the last person to interact with the patient escorts him or her to the receptionist.
“It helped us in a lot of different ways, much more than we thought it would,” says Naomi Guerrero, an Orthopedic technician and SEIU-UHW member who is the team’s union co-lead. “Now we can’t live without it.”
After introducing the check-in sheet, the team saw almost immediate improvement in copay collection. In July 2014, missing copays—known as the total collected variance—totaled $2,166. Between August and November 2014, the total collected variance fell to just $533, a whopping 75 percent improvement. Those numbers are holding steady. The department is averaging a 50 percent increase in copay collections through third quarter 2015.
Besides boosting copay collection, the check-in sheet helped the team improve patient care. Unexpected benefits include:
Before adopting the check-in sheet, the team sought input from a group of staff members and physicians in the department. Incorporating their voices gave them ownership of the project and enabled the team to create a check-in sheet that worked for everyone. For example, physicians rejected an early draft featuring a detailed checklist in favor of blank space to write their orders. And receptionists vetoed an early color-coding system as “too confusing.”
“We learned a lot as we went through our tests of change,” says Guerrero. “We learned there are changes that don’t work out.”
Once team members were happy with the check-in sheet, they spread it to the rest of the department. Convincing their peers to consistently use the check-in sheet took time.
“The medical assistants were resistant because they saw the check-in sheet as an extra step,” says UBT representative Zackry Ellis, a physician assistant and member of UNAC/UHCP.
Some providers also were hesitant to use the form, preferring to speak with staff. That’s when the team turned to Anthony Leone, MD, the department’s physician chief, for help.
“He helped us sway others to try it out,” Guerrero says.
Once staff members understood the benefits of the check-in sheet—enhanced copay collection, improved workflow and better patient care—they all began to use it consistently.
Patients are reaping the benefits of the new form, too.
“Because of the check-in sheet, we’re communicating more with our members,” says UBT representative Esmeralda Montes, a lead medical assistant and SEIU-UHW member. “They feel happy and cared for, and that’s our ultimate goal.”
When one of her teams is able to leap over the roadblocks in its path with the grace of an Olympic hurdler, Charisse Lewis finds herself out of a job.
As a UBT consultant for the Baldwin Park Medical Center in Southern California, it’s an occupational hazard that she looks forward to—again and again. Like coaches everywhere, she enjoys seeing her teams take what they’ve learned and make it their own.
“I do a lot of mentoring,” says Lewis, who acts as coach, counselor and head cheerleader for her facility’s 68 unit-based teams, nudging them past milestones on the Path to Performance, the five-stage “growth chart” UBTs use to measure success. “I’m teaching teams how to function without me.”
For example, she recently helped a team of critical care nurses advance from Level 1 to Level 4 by using an array of strategies from team-building activities to involving union representatives. Another team advanced to Level 4 in part because she coached the management co-lead, who was new to Kaiser Permanente, in how to manage effectively in a partnership culture.
Lewis doesn’t work alone. She’s part of Baldwin Park’s UBT Strategy Group, a SWAT team of union members and managers who target at-risk teams. That team’s goal is to help UBTs excel so they can drive performance to provide the best service, quality, affordability and job satisfaction. Low-performing teams, says Lewis, tend to suffer from poor communication, paltry trust and a lack of transparency.
“It’s hard to get past that stuff,” she says. “They flounder there. They don’t trust each other and it’s hard to be a team.”
Part of Lewis’s talent in helping turn teams around is her skill in assessing stumbling blocks and getting teams engaged with the right resources. She draws on her experience as an LMP coordinator, trainer and improvement advisor to nuture her teams.
“I don’t like to stare at that elephant in the room,” says Lewis. “If it’s a contract issue, then we need a contract specialist. If it’s an HR issue, let’s make sure that HR is involved. I like to address the problem and get the team’s leaders involved, from both labor and management.”
Her approach speaks for itself. Baldwin Park has the highest percentage of high-performing teams in Southern California: Of 68 teams at Baldwin Park, 88 percent are at Levels 4 and 5 on the Path to Performance.
Her passion, integrity and ability to help others overcome their differences and work together to improve member and patient care has earned her praise from LMP leaders throughout Southern California—but Lewis, in turn, credits her success to the many people who support her efforts.
“I have the support of the regional LMP office, and I have a strong support system at the medical center,” she says. “It makes my job easier.”
If you are inspired to improve your team’s communication, just like the ones in Baldwin Park did, here are the next steps for you to take:
For years, success eluded the Baldwin Park Critical Care team. Mired in distrust, staff members didn’t participate in unit-based team meetings. As recently as 2011, few in the 49-member department knew the team existed.
“I didn’t even know what UBT stood for,” says Sheryl Magpali, RN, a member of UNAC/UHCP and now the team’s union co-lead. “No one claimed to be part of it. It was pretty much nonexistent until 2013.”
With a new manager on board, interest in the UBT grew. Staff members from the Critical Care Unit and its sister department, the Step-Down Unit, elected 12 representatives, who in turn chose Magpali as the labor co-lead. Celso Silla, RN, the new department administrator, became the management co-lead.
It was rough going at first.
Attendance was spotty. When the team did meet, members focused on long-simmering grievances about labor and personnel issues. The team reached out to Charisse Lewis, Baldwin Park’s UBT consultant. While consultants often focus on helping teams with using the Rapid Improvement Model and designing tests of change, they also help teams learn to work as teams—clearing up issues that are distracting them from the work at hand.
Lewis’s first steps were to encourage the team’s union members to meet separately with a labor representative.
“That helped relieve the stressors of the union issues,” Magpali says. Now, she says, “team meetings focus on changes that affect the unit, rather than things we have no control over.”
The department—nearly all nurses, but also including ward clerks, who are SEIU-UHW members and one of whom is a team representative—began building trust in other ways, too. At Lewis’s suggestion, staff members organized a bowling night and had dinner together. This summer, they held a backpack drive.
“Charisse has been good at guiding us—attending our meetings, observing and listening and seeing how we can do better,” says Silla.
Lewis didn’t stop with team-building activities. She coached Magpali, a soft-spoken nurse, to speak up during meetings and make her voice heard, and she helped Silla overcome his reluctance to leave his union co-lead in charge of meetings.
Once trust was established, the team could turn its attention to improving patient care, with remarkable results. UBT members have reduced central line-associated bloodstream infections from five in 2014 to none as of August of this year. Buoyed by that success, they are working to reduce catheter-associated infections.
Silla attributes the improvements to the culture of partnership and putting frontline employees in charge of decisions that affect their work.
“We would have been in limbo” without Lewis’s guidance, Silla says. “Now we’re on the same page. We can be a Level 5 in the future.”
